Complaint Review: Kristie Paluch QMRP - Wheat Ridge Colorado

The QMRP, Kristie Paluch, and the staff at the community residential home failed to provide the appropriate medical care and treatment necessary to avoid physical harm to the residents resulting in death to one of the residents. Other findings show that residents are being abused by staff, yet Ms. Paluch failed to ensure these incidnets were reported as required by law.

Specifically, Colorado revised Statues 27-10.5-115 provides in part - (a) Every resident shall be entitled to care that is free from abuse.

Surveyor Findings:

Based on QA (Quality Assurance) investigative report review, medical record review and staff interview, it was determined the community residential home failed to provide the appropriate medical care and treatment necessary to avoid physical harm to supplemental sample individual #5. Specifically, the physician failed to transfer the resident to an appropriate treatment facility when s/he exhibited life threatening signs and symptoms.

The findings include:

1. On 11/03/09, the medical record for supplemental sample Individual #5 was reviewed. Diagnoses included right hemispherectomy, seizure disorder, significant neurological disease, hydrocephalus, macrocephaly, spastic hemiparesis and reactive airway disease. S/he was ADL (activities of daily living) dependant, non-verbal and considered medically fragile.

a) Review of VS (vital sign) parameters from 07/01 to 07/14/09 showed:
-BP (blood pressure) ranged from 106/68 - 150/110
-P (pulse) ranged from 72 - 94
-R (respirations) ranged from 12 - 24
-T (temperature) ranged from 94 - 100 degrees Farenheit
-O2 sat (oxygen saturation) ranged from 94 - 98% on 2L of oxygen

2. On 11/03/09, the QA investigative report, SN visit notes and physician orders/progress notes for individual #5 were reviewed and revealed the following sequence of events up to and including the date of her death (07/19/09):

a) S/he was hospitalized and successfully treated for pneumonia on 05/16/09 and again on 06/21/09.

b) On 07/15/09, s/he was assessed to be in stable health and "was slowly improving back to her baseline."

c) On 07/16/09, the SN (skilled nurse) visit note showed a temperature of 100.3 at 6:30 p.m. that was treated with Tylenol. At 10:30 p.m. the temperature was elevated to 100.8 and again Tylenol was administered.

d) On 07/17/09 at approximately 10:00 a.m., s/he was evaluated by the PCP (primary care physician) and was "alert, in no distress, with normal respiratory rate [and] baseline lung/cardiac exam ..."

(i) From 7:30 p.m. to 11:00 p.m. (3.5 hours), seizure activity was documented. Specifically, at 7:30 p.m. the nurse wrote, "ativan given for seizure over 10 minute [duration]." Ativan was repeated at 8 p.m., versed was given at 9:50 p.m. and 10:30 p.m. The seizure resolved at 11:00 p.m.

e) On 07/18/09 at 6:00 a.m., the SN visit note stated, "[VS] T-101, P-132 [range 72-94], R-18, O2 sat 89 -90% [range 94 -98%] and physician notified." the documentation did not include a lung and/or cardiac assessment.

f) On 07/19/09 at 12:50 a.m. an unsigned "Team Note" stated, "received call from house staff ... T-104.9 [range 94-100] and Tylenol was administered, P-155 [range 72-94], R-48 [range 12-24] and O2 saturation 90% on 4.5L oxygen [increased from 2L], BP-unable to auscultate. Physician notified." There was no evidence of any changes to the treatment plan or physicians orders.

Although the QA investigator recalled that the physician had been notified and was directing the care and treatment for Individual #5, there is no evidence in the medical record to support the physician's on-going involvement as her condition dramatically declined. Specifically,

(i) At 1:10 a.m. (20 minutes later) an unsigned "Team Note" stated, "T-102, labored breathing with [R]-36 and coarse breath sounds throughout ... HR (heart rate) 148 ..." There was no indication the physician had been notified.

(ii) At 2:15 a.m. (approximately 1 hour later) an unsigned "Team Note" stated, "[O2 saturation] fluctuating, 90% on 4.5L oxygen to 79% on NRB (non re-breather mask. Oxygen flow rate not indicated) to 64% on 5.5L oxygen." Additionally, on the "Physician Order" notes the nurse wrote, "T-103.6, P-155 and R-40". There was no evidence the physician had been notified and no evidence the nurse had called for emergent assistance.

(iii) At 2:30 a.m. an unsigned "Team Note" stated, "No HR, no R[espirations], no BP. Pronounced deceased by the physician on-call (not identified by name)."

3. On 11/04/09 at approximately 3:00 p.m. the physician was interviewed. When asked why individual #5 was not transported to the hospital for treatment for her change in condition reported as early as 12:50 a.m. s/he stated, "When I got the call at midnight on 07/19/09 and approximately 2 hours prior to individual #5's demise, I knew if I sent her out [to the hospital] s/he would go to [name of hospital]. The co-guardians had initiated a law suit against that hospital and I knew they did not want her to go there even though I never asked them directly. If I had sent her out, I would have had one happy guardian and one mad guardian. One [guardian] was realistic and the other [guardian] wanted everything done. I decided to treat the problems in her home, I did not expect her to die but as it turned out there wasn't enough time."